South Carolina Code of Regulations
Chapter 61 - DEPARTMENT OF HEALTH AND ENVIRONMENTAL CONTROL
Subchapter 61-12 - STANDARDS FOR LICENSING ABORTION CLINICS
Part IV - MEDICAL RECORDS AND REPORTS
Section 61-12.IV.401 - Medical Records. (II)
Universal Citation: SC Code Regs 61-12.IV.401
Current through Register Vol. 48, No. 9, September 27, 2024
Medical records shall be maintained for all patients examined or treated in the clinic. The records shall be completely and accurately documented, readily available, and systematically organized to facilitate the compilation and retrieval of information. All information shall be centralized in the patient's medical record. All entries shall be legibly written or typed, dated and signed.
A. The record shall include as a minimum the following information:
1. A face sheet with patient identification
data, to include but not be limited to: name, address, telephone number, social
security number, date of birth, father's and mother's names when patient is a
minor, husband's name, and name, address and telephone number of person to be
notified in the event of an emergency;
2. Signed consent for the
procedure;
3. Date of initial
examination;
4. Date of
abortion;
5. Referring and
attending physicians' names and phone numbers, if applicable;
6. Complete medical history to include
medications currently being taken;
7. Physical examination, to the extent
necessary to determine the health status of the patient, within 15 days of the
procedure, including detail of findings of pelvic examination and estimated
gestational age, according to the first day of the last menstrual
period;
8. Results of diagnostic
tests and/or examinations, e.g., X-ray, electrocardiography, clinical
laboratory, pathology, consultations, ultrasound;
9. Pre-operative diagnosis;
10. Counselor's notes;
11. Physician's orders;
12. Complete record of abortion procedure to
include:
a. Vital signs, i.e., temperature,
pulse, respiration, and blood pressure, prior to and following the
procedure;
b. Name of procedure
performed;
c. Anesthetic agent
utilized;
d. Name of attending
physician performing the procedure;
e. Names of clinical assistants in
attendance, to include other physicians, physician's assistants, anesthetists,
nurses, or specially-trained technicians;
f. Signature of physician performing the
procedure.
13. Nurses'
notes;
14. Progress notes to
include a post-anesthesia note if general anesthesia is utilized;
15. Attending physician's description of
gross appearance of tissue removed;
16. Final diagnosis;
17. Condition on discharge;
18. Post-op orders and follow-up
care;
19. Documented verification
that the woman has been presented printed materials as required in the Woman's
Right-to-Know Act;
20. In the case
of an unemancipated minor or mentally incompetent person, a copy of the court
order or written consent authorizing the abortion.
B. The attending physician must complete and sign the medical record within 72 hours following discharge.
Disclaimer: These regulations may not be the most recent version. South Carolina may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
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